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HomeMy WebLinkAbout0048 CARLOTTA AVENUE - Health 48 CARLOTTA DR., HYANNIS A= i r�oM 'wt �►�J In 1 �i9 3 frr?��45 5S— IU(�C �•, !, .fir ��Z T��7 f OS 2�s--•3G1 —' az �N n jY3� yG� �ZS�aq �tii<cc�c5 �? Qcc�.�i�3 Ptc� �-� ,� w P ilk! c u sS� � ,� ,� 4 `�'.g " it e.,„r E ''� us '� � y'rp,�t a'xp a ',f•'9'as ""zp � '' f" v�' � `�' u�'�N ;. : �' i : �' '�'�., '��� •try �"=r' i{-4sr�a'}' n f � � � S�"ti� �'�` t � -¢z.3 a J .+ k :: 3 a r � ,���"� - � :. � z� u+,ai. : ��.• '� ��`� ...ai"�` ,z �s� �`it�-�K �#�, s«m'�'&�` 144 �r s'm. �p�x �.d§�k �:.r �v rtx: +�� g`7} k fi x �F�'+ # 2a'� �$ < * • '� �T' s,- 3�f•' k ,�"'s xt �r"3 a x `a i�y1 a`r•t, u,x1` �! 'j1^ra, WT VON!- WQ�Tajo s t ] �" 0 WIT wary v� a 'Nr�r• b `7-77 7- tilt d r e« r e +t� - �. t x� .„r� W,py� {: '� X ✓3 xwt4 R r m ' xa Alf i 1. a ♦zt a; Ate}'`$ 'h4 A x r M , a AS * p, . a F; * to a,� s I - f:3 rl 4dE s s f _ Alf 0 TWA two "fly " - } Sx i Flit IRS an c � 3.x:id IKM y v n L 4a n a • TOWN ILBARNSTABLELOCA.71ON 1 � � 0�7'Gd e SEWAGE # ------ VILLAGE— ASSESSOR'S MAP& LOT — INSTALLER'S NAME PHONE NO. SEMIC TANK CAPACITY LEACHING (FACILITY: (type) ,c c} 5 (size) NO.OF'BEDROOMS BUILDER OR OWNER. PERMITDATE..,._.. CI 10LIANGE DATE:— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —Eevell Private Water Supply Well and Leaching Facility (�ainy weUs exist on site or within 200 feet of leaching facility) .-_.w_ Feet Edge of Wedand and Leaching Facility(If any wetl ds exist vritlaiet 300 kect9 lei g facility) l uriftod ay �1 — 1 Rt 6 w � w 7� � a IILi •" TOWN OF BARNSTABLE LOCATION cZ a t J-A /Q&, e SEWAGE # a 4,5� 3 d �N,'IT_LAGE ASSESSOR'S MAP & LOTA15?'�QP' I INSTALLER'S NAME&PHONE NO. ' S-109- 7 s 3 ,t SEPTIC TANK CAPACITY /® oa T LEACHING FACILITY: (type)()W--4fA� 33 XNO.OF BEDROOMS BUILDER OR OWNER / PERMIT DATE: -2Z S ,/,0 -5 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility_(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300,feet of leaching facility) Feet Furnished by a y n 0O A Q �1 y c Z` TOWN OF BARNSTABLE "j ATION 4/r 6�2 17� � SEWAGE #,2G,0-5—36- e =.LAGE //Xp 1J ASSESSOR'S MAP & LOT: INSTALLER'S NAME&PHONE NO. r .3 d-2 SEPTIC TANK CAPACITY X s 7' /o®y 57 LEACHING FACIL=: (type)!�46 'g• /N-9,r d- (size).3-3 X NO. OF BEDROOMS 73 BUILDER OR OWNER PERMTTDATE: ?� ��a s COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - II yy �: o �► K 0 bo c a 0 y " No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' \\ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppfication for ]h9pool *p!tem Construction 3permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components O Locaoiop Address or Lot No. /�Ip t-7 Owner's Name,Add res and Tel.No. Asserssor's Map/Parcel Installer's Name,Address,and fel.No. Designer's Name,Addx,,s and Tel.No. o 5 2 2 r 3C" Type of Building: Dwelling No.of Bedrooms 4� Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) CaVeria ( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Wumber of sheets Revision Date Title _ r Size-of Septic Tank �iC t S T oUd Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of jjealth. Signe Date 7 Application Approved by Date Application Disapproved for the following reaso s Permit No. Date Issued ' Y . .. .s .«..,- � . rf''!�',"..rt x•Iy.J-rJ' . v .. vy.� .- r rt. .• � or• _•..a.. )-r-S-•......"•.�`�✓r^G..^+.Yt^1�,,:,�r,..� `* -....A,4, ,..- '^..-...-Hs,, .,a.-s ""'y - .,p No. Fee � , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatiowforani.5pool *p!5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System 1:1 Individual Components -Locauop ddress;or Lot No. A Owner's N e,Address and Tel.No. Assessor's Map/Parcel (.� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. yr ' Type of Building: ` Dwelling No.of Bedrooms-" Lot Size sq.ft. Garbage Grinder( , Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow Y gallons! Plan Date Number of sheets ' Revision Date Title Size of Septic Tank r� r � Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected:. r. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system " in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health.Signed r C Date -)X,�:K' Application Approved by e �� / -Ce Date 1�c Application Disapproved for the following reasons v - r Permit No.r; ~ _ Date-Issued THE-COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by at /1 r r A as constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer � ` ` Designer ` �� The issuance of this permit"hail tyot�be construed as a guarantee that the s, stem 11 u c�,�'ades'g�ed Date D `� ( J Inspector �.. J ..st.. ; ?Y .;c.±w- .y,: • _ --..i; _ — — ,✓' THE COMMONWEALTH OF MASSACHUSETTS /OT PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpozar *pztem Construction Permit Permission is hereby granted-to Co struct( )Repair(f ),jpg ( ) 'an System located at ` ! �aT T /YT_ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. l Provided:Cons uctiobe c mlpleted within three years of the date of teem :+ Date:_ l�X� Approved by ,� �� • Town Of BArnstable Regulatory Services Thomas F. Geiler,Director • BAR 1V5F.BLB. ' ass. Public Health Division TEca ° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Forth Date: �IL �Gw� .ILU 2 Installer:Designer: _1Q4L _ rCp ,✓S Address: � Lv�` � � ' Address: ® _ S� A� bZ52,7 On . d was issued a permit to install a (date (installer) septic system at �`� � ��� y V )gsed on a design drawn by (address) M k%o dated (0,, (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the Y Pp g distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. ✓ — � 4{f e rY �i . ? (Inst er s Signature) `r. (I1 si er's Signature) (Af igrier's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTI'rI THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form COMMONWEALTH OF IMASSACHUSETTS 3 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS , l� DEPARTMENT OF ENVIRONMENTAL PROTECTION h L / y TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM PART A CERTIFICATION Property Address: L-,) .01 /� � Owner's.Name �/f� G f/�� Owner's.Address: �� Date of Inspection: T7q I ,L��1 Name of Inspector: plea a print) NS�P��� Company Name. C; T7i, kp'�C • �F50--5 Mailing Address: 1y 90V 00 Wo Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the.time.of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector,pursuant,to Section 15.340 of Title 5(310.CMR 15.000). The system: t/ Passes Conditionally Passes ee s F her Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A C/ CERTIFICATION (continued) Property Address: f /j Owner: Date of Inspectio Inspection Summary: Check A,13,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure cri eria not evaluated are indicated below.. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair;as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existingtank is replaced with a complying' se tic tank a ps approved b the Boardof Health. P PP Y *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is.removed distribution box is leveled or replaced ND explain: The system required pumping more thzn'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3. of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) oz 4 / Property Address: Owner Date of Inspectio : //0 9 (J/ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system Ts failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in.a manner which will protect public health,safety and.the environment: _ Cesspool or privy is within 50 feet of a surface.water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that.protects the public health,safety and environment: . _ The system has aseptic tank.and soil absorption system(SAS)and the SAS.is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water.supply. The system has a septic tank and SAS and the SAS.is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or.more from a private water supply well".Method used to determine distance "This system passes.if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 F Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspectio : �L� 'a4 Ao D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or.system component due to overloaded or clogged SAS or cesspool !� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or _� clogged SAS or cesspool . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is.less than '/2 day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped Vt Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. Any portion of a cesspool or privy is within a Zone l of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50.feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the,above failure criteria exist as described in 310 CMR 15.303,therefore the system fails-The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: The following criteria apply to large systems in addition to the criteria above ( g PP Y g Y yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304;The system owner should contact the appropriate regional office of the Department. 4 Page 5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Yo, &126W Owner• Z. 1l v7v 6L)&.�` Date of Inspectiot S / Check if the following have been done.You must indicate"yes"or"no"as to.each of the followina: Yes No ✓_ Pumping information was provided by the owner,occupant,or Board of Health t/Were any of the system components pumped out in the previous two weeks? V" _ Has the system.received normal flows in the previous two week period? J�Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up W inspected for signs of break out? 1/ as the site ins P g Were all system components,excluding the SAS, located on site Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the.Soil Absorption System(SAS)on the site has been determined based on: Yes no 4/— Existing information.For example,a plan at the Board of Health. i,_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable).[310 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: � "z"i A' sL Owner: i ea Date of Inspection. Z&.qlol FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no); Xe� '- Is laundry on a separate sewage system(yes or no)/7 [if yes separate inspection,required] Laundry system inspected(yes or no)4�p— Seasonal use: (yes or no): Water meter readings, if available.(last 2 years usage(gpd# Sump pump(yes or no):/' d` Last date of occupancy:aChMl l- VM4-,A& COMMERCIAL/INDUSTRIAL 1960— Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,e.tc.); Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings; if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. Was system pumped as p&T of-the inspection(yes or no):� — - If yes, volume pumped: __gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �eptic tank,distribution box,soil absorption system _ cesspool Single g Overflow cesspool _Privy _Shared system(Yes or no)(if yes,attach previous inspection records if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copyof the DEP approval Other(describe): proximate age of Il com onents date installed(if own)and source of'nfo ation: Were sewage odors detected when arriving at the site(yes or no).' 6 Page 7 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Mq Q0(P0/ Owner: Date of inspectiae (� BUILDING SEWER(locate on site.plan/ Depth below grade: Materials of construction:_cast.iron _44 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: t✓(Locate on site plan) Depth below grade: Material of construction:oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: CD k Sludge depth: Distance from top of sludge to bottom of outlet-tee or baffle: vJ Z Scum thickness: r-7 Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle: /P How were.dimensions determined: (2z� �>L��iP.//l Comments(on pumping recommendations, Inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert evidence of leakage, f a9 GREASE TRAP (`locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene=other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.); 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR YOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � ZGL� P Y Owner Date of nspectio. . ,)! / TIGHT or HOLDING TANK• (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: / Material of construction: concrete metal :fiberglasspolyethylene other ex lain g ( P ) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:. o/ (if present mus7 be opened)(locate on site plan) Depth of liquid level above outlet invert: ✓� %" ' Comments(note if box is level and distribution to"outlets equal,any evidence of solids carryover,any evidence of akage into or out of box,etc.): PUMP CHAMBER;,' (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): ` Comments(note condition of pump chamber,:condition of pumps and appurtenances,etc.): 8 i Page 9 of I I OFFICIAL.INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (� SYSTEM INFORMATION(continued) Property Address: T o aw"ZU1 All Owner C!/R •�.Q Date of Inspectio : v SOIL ABSORPTION SYSTEM (SAS):__Z'(Iocate on site plan,excavation not required) If SAS not located explain why: Type . �eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,.number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level-of ponding,damp soil,condition of vegetation, etc. J a ° o CESSPOOLS:/�(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY%locate on site plan) . Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9. Page 10 of l l OFFICIAL JNSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q � t , Owner: .� ',;t� Pr®� Date of Inspectioil/ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. G'W# B O 10 Page 11 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i �y? Owner pc Date of Inspecti p SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water `y feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: � hecked with local excavators, installers-(attach documentation) i/Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 ti Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09- every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes , ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-25-09 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.. """'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Recommend pumping now and every 2 yrs for maintenance. 3/ t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage isposal System• age 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,E,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating:that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s), The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, ? safety and environment: ' ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 3 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ww 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an.overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/ day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® `Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes" or"no"to each of the following, in addition to the questions in Section D. Yes No' ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered `yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] t5msp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601_ 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 12-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 N, Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 Commonwealth of Massachusetts f Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 16 Distance from top of sludge to bottom of outlet tee or baffle 16' 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Tape t5insp official document}03/08•.:• .• - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: galloris per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field is in good condition with no sign of back-up into d-box or surrounding stone t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 J Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I J Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties .to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. h � C c� a t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 I ' Commonwealth of Massachusetts 4 Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Carlotta Ave Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 3-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) m ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. t5insp official document•03/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 j PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FOIE I,-1--xvI 1D I. ����, hereby certify that the engineered plan signed by me dated 05 ,concerning the property located at C'112 -orl,9 'J)1C1AJ L1E- meets al of the ► ti. N following criteria: • This failed system is connected to a residential dwelling only. There arc no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) c.3 , on B) G.W.Elevation +adjustment for high G.W. U 20 r C� i DIFFERENCE BETWEEN A and B IC51 2 SIGN DATE. Z/ Z) NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system Plans. q;luahb folder:pereckmp ,�^ TOWN OF BARNSTABLE LOCATION / C 'q cz'a 1-/,� /� • SEWAGE`# a 0,05� -ada VILLAG A1YA Af,✓;s ASSESSOR'S.MAP & LOT:-.l INSTALLER'S NAME&PHONE NO'. ,,9P,2c if SEPTIC TANK CAPACITY ©oo J-T T LEACHING FACILrI`Y: (type)() (�•�'�,p i✓,�,/riz�Tv2S size) 3.3 x♦O X GD.- NO. OF BEDROOMS . BUILDER OR OWNER\` j PERMTTDATE: _S ,tea S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private'Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1,to 2 rLL �®X `?e-?-=3t,� ` ®�T � ' �r TOWN OF BARNSTABLE C� .,OCATION SEWAGE # VILLAGE �il� �/ S ASSESSOR'S MAP & LOT104W-,17,0/ INSTALLER'S NAME&PHONE NO. h'1Acob4hP/' �n S—LdIC_ SEPTIC TANK CAPACITY tOC7 d LEACHING FACILITY: (type) ?1. (size) IQdC7 NO.OF BEDROOMS r,? BtMDE"R OWNER PERMIT DATE: COMPLIANCE DATE: '"` s Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet Furnished by �� 1 ���� '� � , /� �. . � � � �6R�\ \ �\ i ��'• No . .... r Fes$.... . .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE . Appliration for Bi_npn!3a1 Workri Towitriirtiun Famit Application is hereby made for a Permit to Construct ( ) or Repair NX ) an Individual Sewage Disposal System at: 48 Carlotta...................................................... Hyannis ----------------------------------------------------------•-----........---•--...............---- Locatton Address or Lot No. Mar -E. Griffin ------ -------- •------- -------- •-•--•------•-•--- -------------------•---------••--•--•-•---••------------------•------...--•---...........----..... J.P.Maeomb`id'fe'Jr. Address W . Installer Address d Type of Building Size Lot............................Sq. feet U DwellingM No. of Bedrooms-----------3-------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.........-.gallons Length................ Width--..-----------. Diameter_.------------ Depth_....._.-_...._. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..... ................ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ .1 Test Pit No. ---------------- per inch Depth of Test Pit-------------------- Depth to ground water.............._------ .. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------------------•--------------------- '....................................-.......................................................................... 0 Description of Soil............................=........................................................................................................................................... x Sand & Gravel W ----••••---------- ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•••- VNature of Repairs or Alterations—Answer when applicable...._omi t...cesspools.- ----Instal 1---1_-100 0----. _____ ___________gallon tank. 1 -distribution---box -and-_-1-.-1.000•.._gallon___leachi-ng..plt_.-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en,issued by the b ,,oard of health. Signed - ----------- -- - -- 3/.. .. . 2 5/9 5 . .. .... ...... Pat T.7.---- -:---- e Application,Approved By � Date Application Disapproved for the following reasons: ............ ........................... ---------- ----------------- ----------_......--------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- -------------------------------------- Permit No. Y Dates .� � - Issued � � Dare No.��r...f�. _ FE$... ....3.0..- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applirativii for Di-aip ial Work,5 Cnoii,itrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair a(X ) an Individual Sewage Disposal System at: 48 Carlotta Ave Hyannis L-(yr i--- ress or Lot No. Mary E. Griffin W J.P.Macomb(,, er Jr. Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling.=- No, of Bedrooms.........._3-_-•-------------------_.-.-_Expansion Attic ( ) Garbage Grinder ( ) P`4 Other—Type of.Building ----------------------- --- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Pa Other fixtures ------------------------------- - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter----.----------- Depth................ x Disposal Trench—No_ _________________- Width-----..._-.___-___-_ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..._._-._.._--._-.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) I ~' Percolation Test Results Performed by---------------------- Date...................................... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_-.--..---.-_-_._.__-._. f� Test Pit No. 2.......... .....minutes per inch Depth of Test Pit-_--_-.-:_-____- Depth to ground water........................ --------------------•--•--•..............-............................................................................................... ..... .-•----------- ODescription of Soil............................................................................................................................................ ........................... x Sand & Gravel v ---------------------------------------------------------------------------------------•-•--........-------------------------------------------------------------------------------•---•-•-•------------ W U Nature of Repairs or Alterations—Answer when applicable.-----om--t cesspools. Install - -1000 - -- gallon tank. 1 -distribution box and 1 -1000 gallon leaching pit. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 4ssued by the boar of health. 3/25/95 Signed - - ---------- -- ----- �/� �--------------_---------- Da Application.Approved BY �-• - � ... ....._._ �//"/ .......... ... ..... ----------------_-- Date Application Disapproved for the following reasons- ------------- ----- --------------------- --------------------------- -- ---------------------- ------------------------ Y� Permit No. r- .. - -......_....... Issued ..... --- Dare M� ACHUSETTS THE COMMONWEALTH OF ASS BOARD OF HEALTH TOWN OF BARNSTABLE C�Er#ifirate of C�nmplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX))- by --------------J..P...M.ac.omber....,Tr- ----------------....---- -----.....--------------....------- ----------- ------------------------- ---..---------------------------.---- at . . .40 ..Carlotta_.Ave.._H-va.nn.is_....- ----------------------_---------- ----------- -------- -------------------. ----------- has been installed in accordance with the provisions of TIT I. 5 of The State Environmental C de as describ in the application for Disposal Works Construction Permit NoO' e .��'�..?`�...__. dated _^....�7�A---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS CT�. DATE.... ...7 ..... ....... -.. --- ------------- .. . Inspect ... ------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30.00 No. FEE........................ �i��n�ttl nr�� �u�i��ri�s#Uan ��erntit Permission is hereby granted........J.P.Maeomber.Ji•. to Construct ( ) or Repair (' ) an Individual Sewage Disposal System at No..__._..48 Carlotta Ave Hyannis tMass,- _. Strc as shown on the application for Disposal Works Construction mite "" ------ Date ------------- ..... ................... . �J �. Board of Health DATE.....!:�2...----....-------- -.------ ------------------------.... FORM 36506 HOBBS h WARREN,INC..PUBLISHERS ASSESSORS MAP: 8 _- --- -TEST HOLE LOGS PARCEL: NOTES: 9A FLOOD ZONE: �� �P•�'G/G�� ---- SOIL EVALUATOR:_��1 H1 � • WITNESS: lkk ►lt REFERENCE: LIED_ ' � 1�Q�2_F�/ i / DATE: 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLATION RATE: L 2 M�i Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic ✓' ��ht� TH- 1 TH-2 components prior to installation and setting base elevations. fl 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. This plan is not to be utilized for property line determination nor any other D� 2 LO purpose other than the proposed system installation. &1 3) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. S' > 7) The property is bounded by property corners and property lines. LOCATION MAP J � b # 8 The roe owner shall review design considerations to approve of total • L� *14 �1-{ ) P P rt3' � PP design flow to be considered for design. Receipt of payment for the plan and L� installation based on the plan shall be deemed approval of the design flow. J"�` 9) The existing leach pit(s) shall be pumped and filled with material per Title V 10�� abandonment procedures. Those within the proposed SAS shall be removed .?(1 along with contaminated soil and replaced with clean washed sand per Title V A specs. `€ 10 System components to be 10 feet from water line.) Y Po 11) If a garbage grinder exists it is to be removed and the responsibility of the _. E DES owner to ensure such. SEPT I C SYSTEM' ►uES i GN FLOW ESTIMATE BEDROOMS AT )ID GAL/DAY/BEDROOM - GAL/DAY Io Mla"110 L r`J # 4 # t _ SEPTIC TANK MGAt-/DAY x 2 DAYS - bW (AL. USE ID)b GALLON SEPTIC ANK -WTlin� SOIL ABSORPTION SYSTEM K- S DE AREA: t-�J- �C X I �i 1 _.T �, , _-T__— f K��IUt Z 07D21N� -) 3v 8:)TTOM' AREA: X of 7 ► l�s slow r SEPT I G SYSTEM SECT I ON l ._, .(2 fa�wQ_ -3Z —�vfiyw� ac ivuAtr�� Abb /oo, Gib GAL D B01000 , 7, K �VT" � � : ,,� � ,- SEPTIC TAN 0 SITE AND SEWAGE PLAN r LOCATION : 04'tADTF4 )}1/�U� PREPARED FOR : IJAG J*XPr76 A SCALE. Orr � DAV i D 13 . MASON Rv DATE: w l>5 DBC ENVIRONMENTAL DESIGNS W DATE HEALTH AGENT EAST SANDWICH . MA ( 508) 833- 2177 2